AHRQ Patient Safety Network

The Collection > Surgery

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Safety Target

•Device-related Complications (23)

•Diagnostic Errors (21)

•Identification Errors (69)

•Discontinuities, Gaps, and Hand-Off Problems (54)

•Fatigue and Sleep Deprivation (31)

•Medication Safety (63)

•Medical Complications (55)

•Nonsurgical Procedural Complications (9)

•Surgical Complications (489)

•Transfusion Complications (3)

•Psychological and Social Complications (31)

Origin/Sponsor

•Africa (1)

•Asia (8)

•Australia and New Zealand (9)

Resource Types

•Clinical Guideline (3)

•Journal Article (497)

•Legislation/Regulation (9)

•Meeting/Conference (1)

•Newsletter/Journal (1)

•Newspaper/Magazine Article (77)

•Press Release/Announcement (2)

•Special or Theme Issue (7)

•Tools/Toolkit (9)

•Web Resource (13)

Error Types

•Epidemiology of Errors and Adverse Events (218)

•Active Errors (124)

•Latent Errors (34)

•Near Miss (17)

Approach to Improving Safety

•Quality Improvement Strategies (153)

•Legal and Policy Approaches (48)

•Error Reporting and Analysis (192)

•Communication Improvement (173)

•Human Factors Engineering (127)

•Teamwork (86)

•Specialization of Care (22)

•Logistical Approaches (58)

•Culture of Safety (65)

•Technologic Approaches (66)

•Education and Training (139)

Clinical Areas
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Surgery

•Cardiothoracic Surgery (14)

•General Surgery (19)

•Neurosurgery (11)

•Otolaryngology (8)

•Orthopedic Surgery (17)

•Pediatric Surgery (19)

•Plastic Surgery (6)

•Surgical Oncology (9)

•Urology (2)

•Vascular Surgery (4)

Target Audience

•Health Care Providers (462)

•Health Care Executives and Administrators (463)

•Non-Health Care Professionals (168)

•Patients (71)

Setting of Care

•Hospitals (562)

•Residential Facilities (2)

•Ambulatory Care (11)

•Outpatient Surgery (39)

•Patient Transport (3)

1 - 20 of 646

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COMMENTARY

Improving heparin safety: a multidisciplinary invited conference.

Peterson C, Ham CW, Vanderveen T. Hosp Pharm. 2008;43:491-497.

STUDY

Variations in surgical outcomes associated with hospital compliance with safety practices.

Brooke BS, Dominici F, Pronovost PJ, Makary MA, Schneider E, Pawlik TM. Surgery. 2012;151:651-659.

STUDY

Quality improvement and patient care checklists in intrahospital transfers involving pediatric surgery patients.

Nakayama DK, Lester SS, Rich DR, Weidner BC, Glenn JB, Shaker IJ. J Pediatr Surg. 2012;47:112-118.

BOOK/REPORT

Utah Tenth Anniversary (2001–2011) Patient Safety Report: Identifying Opportunities for Improvement.

Salt Lake City, UT: Utah Department of Health, HealthInsight, Utah Hospital Association; 2012.

BOOK/REPORT

Patient Safety Authority Annual Reports.

Harrisburg, PA: Patient Safety Authority; April 2013.

STUDY

The impact of medical errors on ninety-day costs and outcomes: an examination of surgical patients.

Encinosa WE, Hellinger FJ. Health Serv Res. 2008;43:2067-2085.

STUDY

The impact of resident duty hour reform on hospital readmission rates among Medicare beneficiaries.

Press MJ, Silber JH, Rosen AK, et al. J Gen Intern Med. 2011;26:405-411.

BOOK/REPORT

Tennessee Center for Patient Safety Annual Report 2010.

Nashville, TN: Tennessee Center for Patient Safety; August 2011.

NEWSPAPER/MAGAZINE ARTICLE

Avoidable mistakes rise despite hospital efforts.

Colliver V. San Francisco Chronicle. June 2, 2010;A1.

STUDY

Association between Leapfrog safe practices score and hospital mortality in major surgery.

Qian F, Lustik SJ, Diachun CA, Wissler RN, Zollo RA, Glance LG. Med Care. 2011;49:1082-1088.

STUDY

SBAR M&M: a feasible, reliable, and valid tool to assess the quality of, surgical morbidity and mortality conference presentations.

Mitchell EL, Lee DY, Arora S, et al. Am J Surg. 2012;203:26-31.

STUDY

The simulated ward: ideal for training clinical clerks in an era of patient safety.

Mollo EA, Reinke CE, Nelson C, et al. J Surg Res. 2012;177:E1-E6.

REVIEW

Avoiding wrong site surgery: a systematic review.

DeVine J, Chutkan N, Norvell DC, Dettori JR. Spine. 2010;35(suppl 9):S28-S36.

STUDY

The 80-hour work guidelines and resident survey perceptions of quality.

Biller CK, Antonacci AC, Pelletier S, et al. J Surg Res. 2006;135:275-281.

FACT SHEET/FAQS classic

10 Patient Safety Tips for Hospitals.

Rockville, MD: Agency for Healthcare Research and Quality; Revised December 2009. AHRQ Publication No. 10-M008.

NEWSPAPER/MAGAZINE ARTICLE

5 sure-fire methods: complying with NPSG.03.04.01.

Joint Commission: The Source. January 2012;10:5-6.

REVIEW

Systematic review of safety checklists for use by medical care teams in acute hospital settings—limited evidence of effectiveness.

Ko HCH, Turner TJ, Finnigan MA. BMC Health Serv Res. 2011;11:211.

BOOK/REPORT

To Err Is Human—But Don't Expect to Get Paid For It.

ASQ Quarterly Quality Report. Milwaukee, WI: American Society of Quality; October 2008.

STUDY

Relationship between patient complaints and surgical complications.

Murff HJ, France DJ, Blackford J, et al. Qual Saf Health Care. 2006;15:13-16.

COMMENTARY

Human cognition and the dynamics of failure to rescue: the Lewis Blackman case.

Acquaviva K, Haskell H, Johnson J. J Prof Nurs. 2013;29:95-101.

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